Difficulty: Medium
Average Score: 83%
Simulated
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
Correct answer
B,E
Rationale
Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.